Research

JAMA Psychiatry | Original Investigation

Associations Between Time Spent Using Social Media

and Internalizing and Externalizing Problems Among US Youth
Kira E. Riehm, MS; Kenneth A. Feder, PhD; Kayla N. Tormohlen, MPH; Rosa M. Crum, MD; Andrea S. Young, PhD;
Kerry M. Green, PhD; Lauren R. Pacek, PhD; Lareina N. La Flair, PhD; Ramin Mojtabai, MD

Author Audio Interview

IMPORTANCE Social media use may be a risk factor for mental health problems in adolescents. Supplemental content
However, few longitudinal studies have investigated this association, and none have
quantified the proportion of mental health problems among adolescents attributable to social
media use.

OBJECTIVE To assess whether time spent using social media per day is prospectively
associated with internalizing and externalizing problems among adolescents.

DESIGN, SETTING, AND PARTICIPANTS This longitudinal cohort study of 6595 participants from
waves 1 (September 12, 2013, to December 14, 2014), 2 (October 23, 2014, to October 30,
2015), and 3 (October 18, 2015, to October 23, 2016) of the Population Assessment of
Tobacco and Health study, a nationally representative cohort study of US adolescents,
assessed US adolescents via household interviews using audio computer-assisted
self-interviewing. Data analysis was performed from January 14, 2019, to May 22, 2019.

EXPOSURES Self-reported time spent on social media during a typical day (none, ⱕ30
minutes, >30 minutes to ⱕ3 hours, >3 hours to ⱕ6 hours, and >6 hours) during wave 2.

MAIN OUTCOMES AND MEASURE Self-reported past-year internalizing problems alone,

externalizing problems alone, and comorbid internalizing and externalizing problems during
wave 3 using the Global Appraisal of Individual Needs–Short Screener.

RESULTS A total of 6595 adolescents (aged 12-15 years during wave 1; 3400 [51.3%] male)
were studied. In unadjusted analyses, spending more than 30 minutes of time on social
media, compared with no use, was associated with increased risk of internalizing problems
alone (ⱕ30 minutes: relative risk ratio [RRR], 1.30; 95% CI, 0.94-1.78; >30 minutes to ⱕ3
hours: RRR, 1.89; 95% CI, 1.36-2.64; >3 to ⱕ6 hours: RRR, 2.47; 95% CI, 1.74-3.49; >6 hours:
RRR, 2.83; 95% CI, 1.88-4.26) and comorbid internalizing and externalizing problems (ⱕ30
minutes: RRR, 1.39; 95% CI, 1.06-1.82; >30 minutes to ⱕ3 hours: RRR, 2.34; 95% CI,
1.83-3.00; >3 to ⱕ6 hours: RRR, 3.15; 95% CI, 2.43-4.09; >6 hours: RRR, 4.29; 95% CI,
3.22-5.73); associations with externalizing problems were inconsistent. In adjusted analyses,
use of social media for more than 3 hours per day compared with no use remained
significantly associated with internalizing problems alone (>3 to ⱕ6 hours: RRR, 1.60; 95% CI,
1.11-2.31; >6 hours: RRR, 1.78; 95% CI, 1.15-2.77) and comorbid internalizing and externalizing
problems (>3 to ⱕ6 hours: RRR, 2.01; 95% CI, 1.51-2.66; >6 hours: RRR, 2.44; 95% CI,
1.73-3.43) but not externalizing problems alone.

CONCLUSIONS AND RELEVANCE Adolescents who spend more than 3 hours per day using
social media may be at heightened risk for mental health problems, particularly internalizing
problems. Future research should determine whether setting limits on daily social media use,
increasing media literacy, and redesigning social media platforms are effective means of
reducing the burden of mental health problems in this population.

Author Affiliations: Author

affiliations are listed at the end of this
article.
Corresponding Author: Kira E.
Riehm, MS, Department of Mental
Health, Bloomberg School of Public
Health, Johns Hopkins University,
JAMA Psychiatry. 2019;76(12):1266-1273. doi:10.1001/jamapsychiatry.2019.2325 624 N Broadway, Baltimore, MD
Published online September 11, 2019. 21205 (kriehm@jhu.edu).

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 Associations Between Social Media Time and Internalizing and Externalizing Problems Among US Youth
F
or adolescents in the United States, social media use is
ubiquitous. A 2018 Pew Research Center poll found that
97% of adolescents report using at least 1 of the 7 most
popular social media platforms (YouTube, Instagram, Snap-
chat, Facebook, Twitter, Tumblr, and Reddit). Moreover, digi-
tal media use by adolescents is common: 95% report owning
or having access to a smartphone, and almost 90% report they
are online at least several times a day.1
Social media offers numerous potential benefits to users, in-
cluding exposure to current events, interpersonal connection,
and enhancement of social support networks.2 However, con-
cerns are increasingly raised about potential harms of social me-
dia use.2 One-quarter of adolescents think social media has a
mostly negative influence on people their age, pointing to rea-
sons like rumor spreading, lack of in-person contact, unrealis-
tic views of others’ lives, peer pressure, and mental health issues.1
An increasing body of literature suggests that social me-
dia use is associated with mental health problems in adoles-
cence. Numerous cross-sectional studies and a limited num-
ber of longitudinal studies suggest that high levels of social
media use are associated with internalizing problems, includ-
ing depressive and anxiety symptoms,3-6 although results are
not entirely consistent.7 Some studies also suggest an asso-
ciation between social media use and externalizing prob-
lems, such as bullying and attention problems.8,9 Further-
more, a previous study4 produced mixed results regarding the
possible moderating effect of sex.
The prevalence of major depressive disorder and depres-
sive symptoms has increased among adolescents in the United
States,10,11 and adolescent suicide death and attempt rates have
increased sharply during the past 2 decades.12,13 Some authors14
have postulated that increases in depression may be attribut-
able to rapid increases in social media use. However, evi-
dence of this association in nationally representative samples
is scarce, and little is known about whether reducing time spent
on social media might influence the prevalence of mental
health problems at a national level.
In this article, we build on existing literature by examin-
ing the prospective association of time spent on social media
with internalizing and externalizing problems in a represen-
tative sample of US adolescents. We used data from the Popu-
lation Assessment of Tobacco and Health (PATH) study, which
is a nationally representative, longitudinal cohort of
adolescents.15 Unlike a prior study,16 we adjusted for mental
health problems measured before the exposure, which is criti-
cal for reducing the influence of reverse causality. We hypoth-
esized that greater time spent on social media would prospec-
tively be associated with internalizing and externalizing
problems alone, as well as comorbid problems at 1-year follow-
up. On the basis of past research,5 we also examined whether
these associations differed between males and females.
Methods
Participants
In this longitudinal cohort study, participants were drawn from
the public-use data files of waves 1 (September 12, 2013, to
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Original Investigation Research
Key Points
Question Is time spent using social media associated with mental
health problems among adolescents?
Findings In this cohort study of 6595 US adolescents, increased
time spent using social media per day was prospectively
associated with increased odds of reporting high levels of
internalizing and comorbid internalizing and externalizing
problems, even after adjusting for history of mental health
problems.
Meaning Adolescents who spend more than 3 hours per day on
social media may be at heightened risk for mental health
problems, particularly internalizing problems.
December 14, 2014), 2 (October 23, 2014, to October 30, 2015),
and 3 (October 18, 2015, to October 23, 2016) of the PATH
study.15 The methods of the PATH study have been previ-
ously described.15 In brief, the target population for this sur-
vey was the civilian household population in the United States.
Data were collected in 1-year intervals, starting with wave 1 from
September 12, 2013, to December 14, 2014. Multistage-
stratified sampling was used to obtain a sample of house-
holds from which up to 2 individuals aged 12 to 17 years were
randomly selected to be interviewed. Data analysis was per-
formed from January 14, 2019, to May 22, 2019. After oral par-
ent permission and adolescent assent were obtained, adoles-
cents were interviewed using audio computer-assisted self-
interviewing. The current analyses were considered exempt
from human subjects research according to Johns Hopkins in-
stitutional review board policy because the data were pub-
licly available and deidentified.
The weighted response rate for adolescents during wave
1 was 78.4%, and the weighted retention rate during wave 3
was 83.3%.17 A total of 7595 adolescents (aged 12-15 years dur-
ing wave 1, aged 13-16 years during wave 2, and aged 14-17 years
during wave 3) completed all 3 PATH survey waves. Of these,
1000 adolescents (13.2%) were excluded because they were
missing data on at least 1 variable required for this analysis;
the remaining 6595 adolescents comprised the analytic sample
(eFigure in the Supplement).
Measures
Outcome (Wave 3)
Past-year mental health problems, the outcome of interest,
were assessed during wave 3 using the Global Appraisal of In-
dividual Needs–Short Screener (GAIN-SS).18 The GAIN-SS is a
screening measure intended to identify a probable mental
health disorder and assess symptom severity; it has been vali-
dated in adolescents19 and includes internalizing and exter-
nalizing subscales (eTable 1 in the Supplement). Each item mea-
sures 1 symptom; for this study, symptoms were considered
to be present if the respondent selected in the past month or
2 to 12 months from the response options that indicated the
last time they had experienced that symptom. Symptom counts
were generated for each subscale. Adolescents were classi-
fied as reporting low to moderate (0-3 symptoms) or high (≥4
symptoms) internalizing and externalizing problems. These cut
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 Research Original Investigation Associations Between Social Media Time and Internalizing and Externalizing Problems Among US Youth
Figure 1. Directed Acyclic Graph of the Hypothesized Associations Between Study Variables
and Waves of Measurement for the Exposure, Outcome, and Potential Confounders
Wave 1 Wave 2
2013-2014 2014-2015
(ages 12-15 y) (ages 13-16 y)
• Sex Time spent on social media
• Race/ethnicity
• Age
• BMI
• Parental educational level
• Lifetime alcohol use
• Lifetime marijuana use
• Lifetime internalizing and
externalizing problems
points have been validated for use when making treatment
decisions18 and have previously been used with the PATH
sample.20,21 We combined these subscales to create a single out-
come variable with 4 mutually exclusive categories: no or low
internalizing and externalizing problems, internalizing prob-
lems alone, externalizing problems alone, and comorbid in-
ternalizing and externalizing problems. Comorbid problems
were defined as having all 4 internalizing and 4 or more ex-
ternalizing symptoms.
Exposure (Wave 2)
The exposure of interest was time spent using social media per
day during wave 2. Adolescents who reported that they ever
went online were asked, “Sometimes people use the internet
to connect with other people online through social networks
like Facebook, Google Plus, YouTube, MySpace, Linkedin, Twit-
ter, Tumblr, Instagram, Pinterest, or Snapchat. This is often
called ‘social media.’ Do you have a social media account?” Ado-
lescents who reported that they had a social media account that
they visited were asked, “On a typical day, about how much
total time do you spend on social media sites?” The response
options were up to 30 minutes; more than 30 minutes, up to
3 hours; more than 3 hours, up to 6 hours; and more than 6
hours. We retained these categories for our exposure vari-
able, with an additional category of none for adolescents who
reported not going online, not having a social media account,
or never visiting their social media account.
Covariates (Wave 1)
Potential confounders, including demographic characteris-
tics (ie, sex, age, race, and parental educational level), body
mass index (based on parent-reported weight and height), self-
reported lifetime marijuana use and alcohol use, and scale
scores for lifetime internalizing and externalizing problems,
were adjusted for in the analyses. To ensure that we did not
improperly adjust for mediating variables,22 we used covari-
ates measured at wave 1 instead of wave 2. The full study de-
sign is displayed in Figure 1.
Statistical Analysis
Multinomial logistic regression was used to estimate the asso-
ciations between time spent on social media per day with inter-
nalizing problems alone, externalizing problems alone, and co-
morbid internalizing and externalizing problems (reference
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Wave 3
2015-2016
(ages 14-17 y)
Internalizing and
externalizing problems
The dashed lines represent potential
confounding. The solid line
represents the main association of
interest. BMI indicates body mass
index.
group: no or low internalizing and externalizing problems). Both
unadjusted and adjusted analyses were conducted. Regression
coefficients were exponentiated for interpretation as relative risk
ratios (RRRs). In addition, we used the adjusted model to gen-
erate and plot predicted probabilities of high internalizing and
externalizing problems for each level of social media use for an
otherwise average study participant.
We tested for the presence of a linear trend in the coefficients
for social media use in their relation to each category of mental
health problems by converting the social media use variable to
an ordinal variable and reestimating the adjusted model (ie, a
Mantel test for trend23). A linear trend would suggest that more
time spent on social media is associated with a proportionally
greater likelihood of reporting mental health problems.
We tested whether any observed association of social me-
dia use with mental health problems differed between males
and females by testing an interaction term between social me-
dia use and sex in our adjusted model.
In addition, we estimated the respective proportions of
high internalizing and high externalizing problem cases that
would be potentially prevented if adolescents spent less time
using social media (ie, the population-attributable fraction
[PAF] for social media use). We did this for 4 counterfactual
scenarios that represented increasingly greater population re-
ductions in social media use. In scenario 1, adolescents who
actually used social media more than 6 hours per day would
instead use social media more than 3 hours to 6 hours or less
per day; in scenario 2, adolescents who actually used social me-
dia more than 3 hours per day would instead use social media
more than 30 minutes to 3 hours or less per day; in scenario 3,
adolescents who actually used social media more than 30 min-
utes per day would instead use social media 30 minutes or less
per day; and in scenario 4, adolescents who actually spent any
amount of time on social media per day would instead not
spend any time on social media.
We estimated each scenario by generating a counterfac-
tual population from our adjusted model using the approach
to calculate PAFs described by Greenland and Drescher24 and
Rückinger et al.25 See the eMethods in the Supplement for a
detailed description.
To test whether our results were sensitive to missing data,
we repeated analyses using multiply imputed data. We per-
formed multiple imputation using chained equations and re-
computed the unadjusted, adjusted, and sex-interaction mod-
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 Associations Between Social Media Time and Internalizing and Externalizing Problems Among US Youth Original Investigation Research

Table 1. Descriptive Statistics of Population Characteristics for US Adolescents in the PATH Study, 2013-2016,
Overall and by Internalizing and Externalizing Problemsa
Internalizing Externalizing Internalizing and
Problems Alone Problems Alone Externalizing Problems
Total Sample During Wave 3 During Wave 3 During Wave 3
Variable (N = 6595) (n = 611) (n = 885) (n = 1169)
Time spent on social media
per day during wave 2
None 1125 (16.8) 73 (6.6) 122 (12.4) 122 (10.7)
≤30 min 2082 (31.8) 172 (7.8) 287 (14.4) 283 (13.6)
>30 min to ≤3 h 2000 (30.7) 198 (9.8) 310 (15.5) 390 (19.6)
>3 to ≤6 h 817 (12.3) 98 (11.9) 97 (12.2) 202 (24.6)
>6 h 571 (8.4) 70 (12.1) 69 (12.7) 172 (29.7)
Sex
Male 3400 (51.3) 180 (5.0) 564 (17.3) 423 (12.5)
Female 3195 (48.7) 431 (13.4) 321 (10.5) 746 (23.1)
Race
White only 4563 (70.9) 431 (9.3) 635 (14.5) 831 (18.3)
Black only 1000 (14.8) 69 (6.9) 131 (13.4) 147 (15.0)
Otherb 1032 (14.3) 111 (10.2) 119 (12.3) 191 (17.2)
Parental educational level
Less than high school 1308 (17.0) 116 (8.7) 137 (11.0) 183 (14.4)
High school or 1218 (17.8) 140 (11.5) 133 (11.0) 217 (18.1)
equivalent
Some college or 2072 (31.0) 202 (9.4) 290 (14.3) 417 (19.9) Abbreviations: BMI, body mass index
associate’s degree
(calculated as weight in kilograms
Bachelor's degree 1296 (21.8) 103 (8.1) 199 (15.7) 232 (17.1) divided by height in meters squared);
Advanced degree 701 (12.5) 50 (6.9) 126 (18.7) 120 (16.9) PATH, Population Assessment of
Age, y Tobacco and Health.
a
12-14 4913 (74.2) 443 (8.9) 662 (14.0) 888 (17.8) Data are presented as number
(percentage) of patients unless
15-17 1682 (25.8) 168 (9.5) 223 (13.9) 281 (17.4)
otherwise indicated. Percentages,
BMI, mean (SD) 21.91 (5.03) 22.30 (5.25) 21.53 (4.57) 22.18 (5.09) means, and SDs are weighted using
Lifetime alcohol use the wave 3 all-waves replicate
No 4661 (70.0) 410 (8.6) 590 (13.4) 688 (14.5) weights. All variables were
measured during wave 1 except time
Yes 1934 (30.0) 201 (10.2) 295 (15.5) 481 (25.1)
spent on social media per day,
Lifetime marijuana use which was measured during wave 2.
No 6132 (93.3) 561 (8.9) 826 (14.1) 1062 (17.3) b
The other race category includes
Yes 463 (6.7) 50 (11.2) 59 (12.8) 107 (23.1) participants identifying as American
No. of lifetime 2.19 (1.57) 2.84 (1.37) 2.38 (1.44) 3.19 (1.23) Indian or Alaska Native, Asian
internalizing problems, Indian, Chinese, Filipino, Japanese,
mean (SD) Korean, Vietnamese, other Asian,
No. of lifetime 3.22 (2.12) 3.33 (1.94) 4.09 (1.85) 4.49 (1.78) Native Hawaiian, Guamanian or
externalizing problems, Chamorro, Samoan, and other
mean (SD)
Pacific Islander.

els. We stratified by sex and generated 10 imputed data sets
to account for the hypothesized interaction between sex and
social media use.26
Data for analyses were weighted to be representative of 12-
to 15-year-old adolescents living in the United States in 2013 to
2014. Standard errors were estimated using the wave 3 all-
waves replicate weights constructed using balanced repeated
replication (the Fay method) provided in the PATH data set. Sta-
tistical significance was assessed at a 2-sided P < .05 level. All
analyses were conducted using Stata, version 14 (StataCorp).
3, of the sample of 6595 adolescents, 611 (9.1%) reported in-
ternalizing problems alone, 885 (14.0%) reported externaliz-
ing problems alone, 1169 (17.7%) reported comorbid internal-
izing and externalizing problems, and the remaining 3930
(59.3%) reported no or low problems. During wave 2, a total
of 1125 adolescents (16.8%) reported no social media use, 2082
(31.8%) reported 30 minutes or less, 2000 (30.7%) reported
more than 30 minutes to 3 hours or more, 817 (12.3%) re-
ported more than 3 hours to 6 hours or less, and 571 (8.4%) re-
ported more than 6 hours of use per day. Sample characteris-
tics are given in Table 1.

Association Between Social Media Use

Results
Sample Characteristics
A total of 6595 adolescents (aged 12-15 years during wave 1;
3400 [51.3%] male) were included in the analysis. During wave
and Mental Health Problems
Compared with adolescents who did not use social media, the
use of social media for more than 30 minutes per day was as-
sociated with greater risk of internalizing problems alone (≤30

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 Research Original Investigation Associations Between Social Media Time and Internalizing and Externalizing Problems Among US Youth

Table 2. Unadjusted and Adjusted RRRs for Each Category of Social Media Use Associated With Internalizing and Externalizing Problems
Among 6595 US Adolescents in the PATH Study, 2013-2016a
Comorbid Internalizing
Internalizing Problems Alone Externalizing Problems Alone and Externalizing Problems
Variable RRR (95% CI) aRRR (95% CI) RRR (95% CI) aRRR (95% CI) RRR (95% CI) aRRR (95% CI)
Time spent on social
media per day during
wave 2
None 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]
≤30 min 1.30 (0.94-1.78) 1.23 (0.89-1.71) 1.28 (0.98-1.67) 1.18 (0.89-1.56) 1.39 (1.06-1.82) 1.27 (0.97-1.67)
>30 min to ≤3 h 1.89 (1.36-2.64) 1.37 (0.96-1.94) 1.60 (1.16-2.21) 1.37 (0.98-1.92) 2.34 (1.83-3.00) 1.59 (1.23-2.05)
>3 to ≤6 h 2.47 (1.74-3.49) 1.60 (1.11-2.31) 1.36 (0.97-1.90) 1.22 (0.86-1.72) 3.15 (2.43-4.09) 2.01 (1.51-2.66)
>6 h 2.83 (1.88-4.26) 1.78 (1.15-2.77) 1.59 (1.07-2.37) 1.40 (0.90-2.19) 4.29 (3.22-5.73) 2.44 (1.73-3.43)
Sex
Male NA 0.38 (0.30-0.47) NA 1.25 (1.03-1.53) NA 0.51 (0.43-0.61)
Female NA 1 [Reference] NA 1 [Reference] NA 1 [Reference]
Race
White only NA 1 [Reference] NA 1 [Reference] NA 1 [Reference]
Black only NA 0.65 (0.50-0.83) NA 0.86 (0.67-1.10) NA 0.70 (0.54-0.91)
Otherb NA 1.00 (0.73-1.36) NA 0.85 (0.67-1.09) NA 0.86 (0.68-1.09)
Parental educational level
Less than high school NA 1 [Reference] NA 1 [Reference] NA 1 [Reference]
High school or NA 1.38 (1.05-1.82) NA 0.99 (0.75-1.31) NA 1.23 (0.93-1.63)
equivalent
Some college or NA 1.17 (0.90-1.51) NA 1.29 (1.02-1.63) NA 1.37 (1.08-1.75)
associate’s degree
Bachelor's degree NA 0.99 (0.72-1.34) NA 1.34 (0.99-1.81) NA 1.18 (0.89-1.57)
Advanced degree NA 0.89 (0.60-1.32) NA 1.69 (1.24-2.31) NA 1.28 (0.91-1.79)
Age, y
12-14 NA 1 [Reference] NA 1 [Reference] NA 1 [Reference]
15-17 NA 0.94 (0.77-1.14) NA 0.94 (0.79-1.12) NA 0.82 (0.70-0.96)
BMI NA 1.00 (0.98-1.02) NA 0.99 (0.97-1.00) NA 1.00 (0.98-1.01)
Lifetime alcohol use
No NA 1 [Reference] NA 1 [Reference] NA 1 [Reference]
Yes NA 1.02 (0.84-1.25) NA 0.97 (0.82-1.14) NA 1.17 (1.00-1.36)
Lifetime marijuana use
No NA 1 [Reference] NA 1 [Reference] NA [1 [Reference]
Yes NA 0.94 (0.65-1.37) NA 0.67 (0.47-0.95) NA 0.71 (0.54-0.95)
Lifetime internalizing NA 1.57 (1.45-1.71) NA 1.00 (0.93-1.07) NA 1.48 (1.38-1.60)
problems
Lifetime externalizing NA 0.97 (0.91-1.03) NA 1.43 (1.35-1.51) NA 1.36 (1.27-1.44)
problems
Abbreviations: aRRR, adjusted relative risk ratio; BMI, body mass index measured during wave 1 except time spent on social media per day, which was
(calculated as weight in kilograms divided by height in meters squared); NA, not measured during wave 2.
applicable; PATH, Population Assessment of Tobacco and Health; RRR, relative b
The other race category includes participants identifying as American Indian or
risk ratio. Alaska Native, Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese,
a
The aRRRs are adjusted for all covariates listed in Table 1. The reference other Asian, Native Hawaiian, Guamanian or Chamorro, Samoan, and other
category is no internalizing or externalizing problems. All variables were Pacific Islander.

minutes: RRR, 1.30; 95% CI, 0.94-1.78; >30 minutes to ≤3 hours:
RRR, 1.89; 95% CI, 1.36-2.64; >3 to ≤6 hours: RRR, 2.47; 95%
CI, 1.74-3.49; >6 hours: RRR, 2.83; 95% CI, 1.88-4.26) and co-
morbid internalizing and externalizing problems (≤30 min-
utes: RRR, 1.39; 95% CI, 1.06-1.82; >30 minutes to ≤3 hours:
RRR, 2.34; 95% CI, 1.83-3.00; >3 to ≤6 hours: RRR, 3.15; 95%
CI, 2.43-4.09; >6 hours: RRR, 4.29; 95% CI, 3.22-5.73) (Table 2).
In the adjusted model, the associations for the 2 highest cat-
egories of social media use persisted for internalizing prob-
lems alone (>3 to ≤6 hours: RRR, 1.60; 95% CI, 1.11-2.31; >6
hours: RRR, 1.78; 95% CI, 1.15-2.77), and the associations for
the 3 highest categories of social media use persisted for co-
morbid internalizing and externalizing problems (>30 min-
utes to ≤3 hours: RRR, 1.59; 95% CI, 1.23-2.05; >3 to ≤6 hours:
RRR, 2.01; 95% CI, 1.51-2.66; >6 hours: RRR, 2.44; 95% CI, 1.73-
3.43). In contrast, in unadjusted analyses, the association of
social media use with externalizing problems was inconsis-
tent (≤30 minutes: RRR, 1.28; 95% CI, 0.98-1.67; >30 minutes
to ≤3 hours: RRR, 1.60; 95% CI, 1.16-2.21; >3 to ≤6 hours: RRR,
1.36; 95% CI, 0.97-1.90; >6 hours: RRR, 1.59; 95% CI, 1.07-
2.37) and not significant in the adjusted analysis (≤30 min-
utes: RRR, 1.18; 95% CI, 0.89-1.56; >30 minutes to ≤3 hours:

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 Associations Between Social Media Time and Internalizing and Externalizing Problems Among US Youth Original Investigation Research

RRR, 1.37; 95% CI, 0.98-1.92; >3 to ≤6 hours: RRR, 1.22; 95%
CI, 0.86-1.72; >6 hours: RRR, 1.40; 95% CI, 0.90-2.19) (Table 2).
The predicted probabilities of high internalizing, externaliz-
ing, and comorbid problems for each level of social media use,
with all other covariates set to their mean, are displayed in
Figure 2.
We observed a significant linear trend in the coefficients
for both internalizing (F1,99 = 8.86, P = .004) and comorbid
problems (F1,99 = 35.16, P < .001); as time on social media in-
creased, the odds of these outcomes increased proportion-
ately. In contrast, we observed no association for externaliz-
ing problems (F1,99 = 2.25, P = .14).
We observed no statistically significant interaction be-
tween social media use and sex for internalizing (F4,96 = 0.84,
P = .50), externalizing (F4,96 = 0.32, P = .86), or comorbid prob-
lems (F4,96 = 0.73, P = .57).
All PAF estimates are given in Table 3. On the basis of our
adjusted model assuming no confounding, 0.8% to 18.9% of
internalizing problems and 0.8% to 15.3% of externalizing prob-
lems could be prevented if participants had instead used less
social media.
Results of analyses using multiple imputation methods did
not differ appreciably from the main analyses (eTable 2 in the
Supplement).
Discussion
Numerous mechanisms could account for the associa-
tion between social media use and internalizing problems. Ado-
lescents who engage in high levels of social media use may ex-
perience poorer quality sleep, which may be a mediator on the
pathway to internalizing problems.27 Time spent on social me-
dia may increase the risk of experiencing cyberbullying, which
has a strong association with depressive symptoms.28 Social
media may also expose adolescents to idealized self-
presentations that negatively influence body image and en-
courage social comparisons.4 Poor emotion regulation and lack
of social interaction may also be associated with social media
use and contribute to symptoms of anxiety and depression.29
These mechanisms are potentially consistent with the no-
tion that spending less time on social media may contribute
to mental health. In fact, the PAFs obtained in our study sug-
gest that if adolescents using social media for more than 30
minutes per day had instead used it for 30 minutes or less, there
would have been 9.4% fewer high internalizing problem cases
and 7.3% fewer high externalizing problem cases. Of impor-
tance, this is not meant to imply that reductions in mental
health problems would definitively happen if social media use
Figure 2. Adjusted Proportion of Internalizing Problems, Externalizing
Problems, and Comorbid Internalizing and Externalizing Problems
Stratified by Category of Time Spent on Social Media per Day
Among US Adolescents in the Population Assessment of Tobacco
and Health Study, 2013-2016

Consistent with a prior study,4 we found that adolescent social

25
media use was prospectively associated with increased risk of Time spent on social media per day
comorbid internalizing and externalizing problems as well as None >3 h to ≤6 h
≤30 min >6 h
internalizing problems alone. This association remained sig- 20
>30 min to ≤3 h
Mental Health Problems, %

nificant after adjusting for demographics, past alcohol and mari-

juana use, and, most importantly, a history of mental health
15
problems, which mitigates the possibility that reverse causal-
ity explains these findings. In contrast, we did not find an as-
sociation of social media use with externalizing problems alone. 10

This finding suggests that the association of social media use

with comorbid problems occurs primarily because of the asso- 5
ciation of social media with internalizing problems and the high
comorbidity of internalizing and externalizing problems. Un-
0
like a prior study,4 we found no evidence of moderation by sex, Internalizing Externalizing Comorbid
Problems Only Problems Only Problems
perhaps because of the simplicity of our social media use vari-
able, which could not capture the nature of interactions on so-
Error bars indicate 95% CIs.
cial media that may differ by sex.

Table 3. Estimated Percentages of Adolescent Mental Health Problem Cases Eliminated

in Each Counterfactual Scenario of Time Spent on Social Mediaa

Amount of Time Cases, % (95% CI)

Spent on Social Internalizing Externalizing
Media per Day Only Only Comorbid All Internalizing All Externalizing
No more than
a
The All Internalizing column
6h 0.2 (0.2 to 0.2) 0.4 (0.3 to 0.4) 1.2 (1.1 to 1.2) 0.8 (0.8 to 0.9) 0.8 (0.8.0.9)
includes cases of internalizing only
3h 2.3 (2.2 to 2.4) −3.0 (−3.1 to 5.5 (5.3 to 5.6) 4.4 (4.3 to 4.5) 1.7 (1.6 to 1.8) and comorbid internalizing and
−2.9)
externalizing problems. The All
30 min 3.4 (3.3 to 3.5) 0.7 (0.6 to 0.8) 12.4 (12.2 to 9.4 (9.2 to 9.5) 7.3 (7.1 to 7.4) Externalizing column includes cases
12.7)
of externalizing only and comorbid
No time spent on 12.7 (12.5 to 6.9 (6.7 to 7) 22.0 (21.8 to 18.9 (18.7 to 15.3 (15.2 to internalizing and externalizing
social media 12.9) 22.3) 19.1) 15.5) problems.

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 Research Original Investigation Associations Between Social Media Time and Internalizing and Externalizing Problems Among US Youth

were reduced or that all social media use is harmful. Instead,
these PAFs suggest the potential influence of our findings on
the population at a national level assuming a causal effect of
social media use and no confounding—both strong assump-
tions. Future research could improve on our PAF estimates by
using data from randomized clinical trials (RCTs).
Our findings must be balanced with the potential ben-
efits of social media use, which include exposure to current
events, communication over geographic barriers, and social in-
clusion for those who may be otherwise excluded in their day-
to-day lives (eg, lesbian, bisexual, transgender, queer, and ques-
tioning youth).2 A limitation of our study is that we measured
overall time spent on social media; prior studies30-32 have found
that social media use may be positively or negatively associ-
ated with mental health depending on which platforms are
used and how. Nevertheless, a number of interventions could
lead to a reduction in time spent on social media by adoles-
cents, while still allowing for the benefits of such use. The
American Academy of Pediatrics has developed a Family Me-
dia Use Plan, which can be tailored to specific developmental
phases and help parents set reasonable rules for digital media
use.2 Pediatricians and teachers are essential for promoting
these plans, as well as helping parents identify problematic so-
cial media use in their children.33 There is also evidence that
interventions that promote media literacy, defined as “spe-
cific knowledge and skills that can help critical understand-
ing and usage of the media,”34(p 455) counteract the harmful as-
sociation of media use with behavioral health.34 Also, there is
an increasing movement to improve the design of social me-
dia platforms; a notable recent example is not displaying the
number of “likes” that an Instagram post receives.35 We be-
lieve that technology companies and regulators responsible for
social media platforms should consider how these platforms
can be designed to minimize risk of mental health problems.
Some researchers have raised concerns that studies on tech-
nology use and well-being are limited by publication bias.36 We
believe that this is a legitimate concern given that many studies
on this topic, including the present study, are secondary analy-
ses of data not collected for the purpose of studying social
media.36 There appears to be an urgent need for experimental
research, specifically a priori registered RCTs that examine in-
terventions designed to reduce social media use. Our study find-
ings suggest a population-level association between social me-
dia use and mental health problems, and evidence from RCTs
could build on this by examining changes in mental health as a
result of changes in social media use. The existing observa-
tional study findings and at least 1 RCT in college students37 ap-
pear to be sufficient to justify investment in these trials. In ad-
dition, RCTs may be valuable for developing clinical guidelines
and informing regulatory policy for social media design.
Limitations
Some limitations of this study should be noted. First, adoles-
cents self-reported the exposure and outcome, which may in-
flate the observed associations. Second, we measured mental
health problems with a self-report questionnaire rather than a
diagnostic interview. Third, the validity of self-reported time
spent on social media in the PATH study is unknown. Some re-
search suggests that self-reported time on social media may ex-
ceed actual use38; future studies should consider the use of digi-
tal trace data to capture actual time spent using social media.39
Fourth, social media use continues to change rapidly over time;
although our data were collected relatively recently, they may
not reflect current trends. Fifth, although our study design miti-
gates the possibility of reverse causality, some residual con-
founding from imprecise measurement of prior mental health
problems may have been present. Sixth, it remains possible that
mental health problems are prospectively associated with so-
cial media use, but we could not examine this in the present study
because of data limitations. Seventh, it is possible that the ob-
served associations were an artifact of unmeasured confound-
ing. Although we controlled for a number of potential confound-
ers, there may be others, such as physical activity, that we were
unable to include because of data limitations.
Conclusions
This study suggests that increased time spent on social media
may be a risk factor for internalizing problems in adolescents.
Future research should determine whether setting limits on daily
social media use, increasing media literacy, and redesigning so-
cial media platforms are effective means of reducing the bur-
den of mental health problems in this population.

ARTICLE INFORMATION
Accepted for Publication: June 14, 2019.
Published Online: September 11, 2019.
doi:10.1001/jamapsychiatry.2019.2325
Author Affiliations: Department of Mental Health,
Bloomberg School of Public Health, Johns Hopkins
University, Baltimore, Maryland (Riehm, Feder,
Tormohlen, Crum, Mojtabai); Department of
Epidemiology, Bloomberg School of Public Health,
Johns Hopkins University, Baltimore, Maryland
(Crum); Welch Center for Prevention, Epidemiology
and Clinical Research, Johns Hopkins University,
Baltimore, Maryland (Crum); Department of
Psychiatry and Behavioral Sciences, Johns Hopkins
University, Baltimore, Maryland (Crum, Mojtabai);
Division of Child and Adolescent Psychiatry, School
of Medicine, Johns Hopkins University, Baltimore,
Maryland (Young); Department of Behavioral and
Community Health, University of Maryland, College
Park, College Park (Green); Department of
Psychiatry and Behavioral Sciences, Duke
University School of Medicine, Durham, North
Carolina (Pacek); Washington State Department of
Health, Olympia (La Flair).
Author Contributions: Ms Riehm had full access to
all the data in the study and takes responsibility for
the integrity of the data and the accuracy of the
data analysis.
Concept and design: Riehm, Feder, Crum, Green,
La Flair, Mojtabai.
Acquisition, analysis, or interpretation of data:
Riehm, Feder, Tormohlen, Young, Green, Pacek,
La Flair.
Drafting of the manuscript: Riehm, Feder, Pacek.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Riehm, Feder, Green, Pacek.
Administrative, technical, or material support:
Green.
Supervision: Crum, Green, Mojtabai.
Conflict of Interest Disclosures: Dr Young
reported receiving grants from the National
Institute on Drug Abuse and the Brain and Behavior
Research Foundation during the conduct of the
study, receiving grants from Supernus
Pharmaceuticals and Psychnostics LLC outside the
submitted work, and receiving personal fees from
University of Montana's American Indian/Alaska
Native Clinical Translational Program. Dr Pacek
reported receiving grants from the National
Institute on Drug Abuse during the conduct of the
study. No other disclosures were reported.

1272 JAMA Psychiatry December 2019 Volume 76, Number 12 (Reprinted) jamapsychiatry.com

© 2019 American Medical Association. All rights reserved.

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 Associations Between Social Media Time and Internalizing and Externalizing Problems Among US Youth
Funding/Support: Ms Riehm was supported by
grant 5T32MH014592-39 from the National
Institute of Mental Health Psychiatric Epidemiology
Training Program (Peter Zandi, principal
investigator) and by a doctoral foreign study award
from the Canadian Institutes of Health Research. Dr
Feder was supported by National Research and
Service Award F31DA044699 from the National
Institute on Drug Abuse. Ms Tormohlen was
supported by grant T32DA007292 (Renee M.
Johnson, principal investigator), Dr Young was
supported by grant K23DA044288, and Dr Pacek
was supported by grant K01DA043413 from the
National Institute on Drug Abuse.
Role of the Funder/Sponsor: The funding sources
had no role in the design and conduct of the study;
collection, management, analysis, and
interpretation of the data; preparation, review, or
approval of the manuscript; and decision to submit
the manuscript for publication.
REFERENCES
1. Pew Research Center. Teens, social media &
technology. 2018. https://www.pewinternet.org/
wp-content/uploads/sites/9/2018/05/PI_2018.05.
31_TeensTech_FINAL.pdf. Accessed April 11, 2019.
2. Council on Communications and Media. Media
use in school-aged children and adolescents.
Pediatrics. 2016;138(5):e20162592. doi:10.1542/peds.
2016-2592
3. Zink J, Belcher BR, Kechter A, Stone MD,
Leventhal AM. Reciprocal associations between
screen time and emotional disorder symptoms
during adolescence. Prev Med Rep. 2019;13:281-288.
doi:10.1016/j.pmedr.2019.01.014
4. McCrae N, Gettings S, Purssell E. Social media
and depressive symptoms in childhood and
adolescence: a systematic review. Adoles Res Rev.
2017;2(4):315-330. doi:10.1007/s40894-017-0053-
4 disorders and crime/violence problems among
5. Primack BA, Swanier B, Georgiopoulos AM, Land
SR, Fine MJ. Association between media use in
adolescence and depression in young adulthood:
a longitudinal study. Arch Gen Psychiatry. 2009;66
(2):181-188. doi:10.1001/archgenpsychiatry.2008.532
6. Toseeb U, Inkster B. Online social networking
sites and mental health research. Front Psychiatry.
2015;6:36.
7. Jelenchick LA, Eickhoff JC, Moreno MA.
“Facebook depression?” social networking site use
and depression in older adolescents. J Adolesc Health.
2013;52(1):128-130. doi:10.1016/j.jadohealth.2012.
05.008
8. Ra CK, Cho J, Stone MD, et al. Association of
digital media use with subsequent symptoms of
attention-deficit/hyperactivity disorder among
adolescents. JAMA. 2018;320(3):255-263. doi:10.
1001/jama.2018.8931
9. Galica VL, Vannucci A, Flannery KM,
Ohannessian CM. Social media use and conduct
problems in emerging adults. Cyberpsychol Behav
Soc Netw. 2017;20(7):448-452. doi:10.1089/cyber.
2017.0068
10. Mojtabai R, Olfson M, Han B. National trends in
the prevalence and treatment of depression in
adolescents and young adults. Pediatrics. 2016;138
(6):e20161878. doi:10.1542/peds.2016-1878
11. Twenge JM, Cooper AB, Joiner TE, Duffy ME,
Binau SG. Age, period, and cohort trends in mood
jamapsychiatry.com
© 2019 American Medical Association. All rights reserved.
Downloaded from jamanetwork.com by Pablo Ryan on 03/12/2024
disorder indicators and suicide-related outcomes in
a nationally representative dataset, 2005-2017.
J Abnorm Psychol. 2019;128(3):185-199. doi:10.
1037/abn0000410
12. Hedegaard H, Curtin SC, Warner M. Suicide
Mortality in the United States, 1999–2017. NCHS
Data Brief No. 330. Hyattsville, MD: National Center
for Health Statistics; 2018.
13. Burstein B, Agostino H, Greenfield B. Suicidal
attempts and ideation among children and
adolescents in US emergency departments,
2007-2015 [published online April 8, 2019]. JAMA
Pediatr. doi:10.1001/jamapediatrics.2019.0464
14. Twenge JM, Martin GN, Campbell WK.
Decreases in psychological well-being among
American adolescents after 2012 and links to screen
time during the rise of smartphone technology.
Emotion. 2018;18(6):765-780. doi:10.1037/
emo0000403
15. Hyland A, Ambrose BK, Conway KP, et al.
Design and methods of the Population Assessment
of Tobacco and Health (PATH) Study. Tob Control.
2017;26(4):371-378. doi:10.1136/tobaccocontrol-2016-
052934
16. VanderWeele TJ, Jackson JW, Li S. Causal
inference and longitudinal data: a case study of
religion and mental health. Soc Psychiatry Psychiatr
Epidemiol. 2016;51(11):1457-1466. doi:10.1007/
s00127-016-1281-9
17. US Department of Health and Human Services,
National Institutes of Health, National Institute on
Drug Abuse, Food and Drug Administration Center
for Tobacco Products. Population Assessment of
Tobacco and Health (PATH) Study. Ann Arbor, MI:
PATH; 2017.
18. Dennis ML, Chan YF, Funk RR. Development
and validation of the GAIN Short Screener (GSS) for
internalizing, externalizing and substance use
adolescents and adults. Am J Addict. 2006;15(suppl
1):80-91. doi:10.1080/10550490601006055
19. McDonell MG, Comtois KA, Voss WD, Morgan
AH, Ries RK. Global Appraisal of Individual Needs
Short Screener (GSS): psychometric properties and
performance as a screening measure in
adolescents. Am J Drug Alcohol Abuse. 2009;35(3):
157-160. doi:10.1080/00952990902825421
20. Green VR, Conway KP, Silveira ML, et al. Mental
health problems and onset of tobacco use among
12- to 24-year-olds in the PATH study. J Am Acad
Child Adolesc Psychiatry. 2018;57(12):944-954.e4.
doi:10.1016/j.jaac.2018.06.029
21. Riehm KE, Young AS, Feder KA, et al. Mental
health problems and initiation of e-cigarette and
combustible cigarette use. Pediatrics. 2019;144(1):
e20182935.
22. Schisterman EF, Cole SR, Platt RW.
Overadjustment bias and unnecessary adjustment
in epidemiologic studies. Epidemiology. 2009;20
(4):488-495. doi:10.1097/EDE.0b013e3181a819a1
23. Mantel N. The detection of disease clustering
and a generalized regression approach. Cancer Res.
1967;27(2):209-220.
24. Greenland S, Drescher K. Maximum likelihood
estimation of the attributable fraction from logistic
models. Biometrics. 1993;49(3):865-872. doi:10.
2307/2532206
(Reprinted) JAMA Psychiatry December 2019 Volume 76, Number 12
Original Investigation Research
25. Rückinger S, von Kries R, Toschke AM. An
illustration of and programs estimating attributable
fractions in large scale surveys considering multiple
risk factors. BMC Med Res Methodol. 2009;9(1):7.
doi:10.1186/1471-2288-9-7
26. Tilling K, Williamson EJ, Spratt M, Sterne JA,
Carpenter JR. Appropriate inclusion of interactions
was needed to avoid bias in multiple imputation.
J Clin Epidemiol. 2016;80:107-115. doi:10.1016/j.
jclinepi.2016.07.004
27. Li X, Buxton OM, Lee S, Chang AM, Berger LM,
Hale L. Sleep mediates the association between
adolescent screen time and depressive symptoms.
Sleep Med. 2019;57:51-60. doi:10.1016/j.sleep.2019.
01.029
28. Bottino SMB, Bottino CM, Regina CG, Correia
AV, Ribeiro WS. Cyberbullying and adolescent
mental health: systematic review. Cad Saude Publica.
2015;31(3):463-475. doi:10.1590/0102-311x00036114
29. Hoge E, Bickham D, Cantor J. Digital media,
anxiety, and depression in children. Pediatrics.
2017;140(suppl 2):S76-S80. doi:10.1542/peds.2016-
1758G
30. Seabrook EM, Kern ML, Rickard NS. Social
networking sites, depression, and anxiety:
a systematic review. JMIR Ment Health. 2016;3(4):
e50. doi:10.2196/mental.5842
31. Baker DA, Algorta GP. The relationship between
online social networking and depression:
a systematic review of quantitative studies.
Cyberpsychol Behav Soc Netw. 2016;19(11):638-648.
doi:10.1089/cyber.2016.0206
32. Ilakkuvan V, Johnson A, Villanti AC, Evans WD,
Turner M. Patterns of social media use and their
relationship to health risks among young adults.
J Adolesc Health. 2019;64(2):158-164. doi:10.1016/j.
jadohealth.2018.06.025
33. Joshi SV, Stubbe D, Li S-TT, Hilty DM. The use of
technology by youth: implications for psychiatric
educators. Acad Psychiatry. 2019;43(1):101-109.
doi:10.1007/s40596-018-1007-2
34. Jeong S-H, Cho H, Hwang Y. Media literacy
interventions: a meta-analytic review. J Commun.
2012;62(3):454-472. doi:10.1111/j.1460-2466.2012.
01643.x
35. Yurieff K. Instagram is testing hiding your likes.
CNN website. https://www.cnn.com/2019/04/30/
tech/instagram-hiding-likes/index.html. Accessed
June 12, 2019.
36. Orben A, Przybylski AK. The association
between adolescent well-being and digital
technology use. Nat Hum Behav. 2019;3(2):173-182.
doi:10.1038/s41562-018-0506-1
37. Hunt MG, Marx R, Lipson C, et al. No more
FOMO: limiting social media decreases loneliness
and depression. J Soc Clin Psychol. 2018;37(10):751-
768. doi:10.1521/jscp.2018.37.10.751
38. Junco R. Comparing actual and self-reported
measures of Facebook use. Comput Human Behav.
2013;29(3):626-631. doi:10.1016/j.chb.2012.11.007
39. Stier S, Breuer J, Siegers P, et al. Integrating
survey data and digital trace data: key issues in
developing an emerging field [published online
April 24, 2019]. Soc Sci Comput Rev. doi:10.1177/
0894439319843669
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